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Knowledge of human papillomavirus among high school students can be

increased by an educational intervention

Article  in  International Journal of STD & AIDS · August 2010

DOI: 10.1258/ijsa.2010.010063 · Source: PubMed

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ORIGINAL RESEARCH ARTICLE

Knowledge of human papillomavirus among high school

students can be increased by an educational intervention

M Gottvall RN*†, T Tydén PhD*, A T Höglund PhD* and M Larsson PhD†

*Department of Public Health and Caring Sciences; †Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden

Summary: The aim of this study was to evaluate the effect of an educational intervention concerning human papillomavirus (HPV)
directed at Swedish first year high school students. The intervention consisted of a class room lesson, a website and a folder.
Outcome variables were knowledge of HPV and attitudes to preventive methods such as HPV vaccination, condom use and Pap
smear testing. An intervention group (n ¼ 92) was matched with two comparison groups (n ¼ 184). At baseline, the median score for
HPV knowledge was one out of 10 in both groups. At follow-up, the median knowledge score had increased to six in the intervention
group, but was still one in the comparison group (P , 0.001). Attitudes to HPV vaccination, condom use and Pap smear testing
remained the same (P . 0.05). In conclusion, a short school-based intervention can greatly increase the students’ knowledge about
HPV, but attitudes and behaviours are less easy to influence.

Keywords: HPV, prevention, vaccination, condoms

INTRODUCTION vaccine and an appeal has been filed. The final decision regard-
ing which vaccine to use in the programme has therefore not
The incidence of sexually transmitted infections (STIs) has
been made. At present, the quadrivalent vaccine dominates
increased in recent years in Sweden, as in the rest of the
the sales in Sweden with 95% of the market share.
western world.1 – 3 One of the most common STIs is human
Another method to prevent the transmission of HPV is the
papillomavirus (HPV) and some HPV types have been associ-
use of condoms. It reduces the risk of transmission by 70% if
ated with development of cervical cancer, as well as other
the male partner consistently uses a condom during all epi-
anogenital and oropharyngeal cancers/precancers, and genital
sodes of intercourse.12 However, this method is problematic
warts.4 Awareness about the link between an HPV infection
regarding compliance. Oral contraceptives have been associated
and cervical cancer varies, but it is generally low among both
with non-condom use for both men and women (P , 0.05).13
adolescents and adults. Consequently, awareness about
Likewise, it has been shown that the intent to use condoms
methods for preventing HPV and cervical cancer is low.5211
could decline in cases of HPV immunization.14
A Swedish study from 2007 showed that only 1% of the high
Review articles on the efficacy of preventive STI/human
school students in the study were aware of the association
immunodeficiency virus (HIV) interventions among adoles-
between HPV and cervical cancer and 1% were aware of any
cents have highlighted the importance of targeting the beha-
vaccine against HPV.8 In an Italian study, 30% of the adoles-
viours that are most amenable to change, e.g. by emphasizing
cents in the study had heard about HPV infection. As many
condom skills, frequency of condom use and partner communi-
as 42% of them believed that vaccination was a preventive
cation techniques.15,16 Adolescents are not a homogeneous
measure for cervical cancer, 35% believed that condom use
population and interventions should be tailored specifically
was a preventive measure and 36% believed that oral contra-
for subgroups to have optimal effects.16
ception could prevent cervical cancer.7
Internet-based interventions have shown positive effects on
The quadrivalent HPV vaccine has been available in Europe
diet and activity outcomes,17 but the Internet has also been
since 2006 and the bivalent vaccine since 2007. The National
used for HIV prevention. In a randomized controlled trial, it
Board of Health and Welfare in Sweden has recommended a
was concluded that Internet-based interventions for adolescents
school-based vaccination programme for girls between age 10
need to be repeated since a single session promoting
and 12 years starting in 2010. The bivalent vaccine was
condoms had only a minor effect on norms regarding
chosen for the school-based programme. However, this
condom use.18
decision was contested by the manufacturer of the quadrivalent
To our knowledge, no intervention aimed at increasing
the knowledge of HPV among adolescents has been reported.
The principal aim of this study was therefore to evaluate the
Correspondence to: M Gottvall, Department of Public
effect of an educational intervention about HPV and preventive
Health and Caring Sciences, Box 564, 75122 Uppsala,
methods for cervical cancer, such as vaccination, condom
Sweden
use and Pap smear testing. Outcome measures were knowledge
Email: maria.gottvall@pubcare.uu.se
of HPV and attitudes to preventive methods.

International Journal of STD & AIDS 2010; 21: 558 –562. DOI: 10.1258/ijsa.2010.010063
 Gottvall et al. Educational intervention concerning HPV
................................................................................................................................................
METHODS
Design
A quasi-experimental intervention study.
Population and sample
A strategic sample of first year students from both vocational
and theoretical high school programmes were chosen for this
study. The vocational high school programmes prepare for
handcraft professions and the theoretical programmes prepare
for university studies. Four classes from three different high
schools were assigned to the intervention group (IG) and nine
classes from three other high schools were assigned to two com-
parison groups (CG1, CG2). The second comparison group was
included to check for any bias induced by filling in the baseline
questionnaire. The students of comparison group 2 (CG2) did
not participate in the study until they completed the follow-up
questionnaire. CG2 consisted of students from theoretical study
programmes. In the analyses aimed to compare CG1 and CG2,
only students in theoretical study programmes were included.
CG1 consisted of 36 girls and 15 boys from theoretical pro-
grammes. The number of students in each group completing
the questionnaires and participating in the intervention is
shown in Figure 1.
In each of the three groups, the IG and the two comparison
groups, at least 110 students were considered to be required
to be able to show a 5% difference between the IG and each
comparison group with a power of 80%. The significance
level was P , 0.05.
Theoretical framework
The intervention was based on the Health Belief Model (HBM),
which is a commonly used model in health campaigns.
According to the HBM, people will take action to prevent an
ill-health condition if they consider themselves to be susceptible
to that condition ( perceived susceptibility to a health threat); if
they believe it would have potentially serious consequences
( perceived severity); if they believe that a course of action avail-
able to them would be beneficial in reducing either their
susceptibility to or the severity of the condition; and if they
believe that the anticipated barriers to, or cost of, taking the
action are outweighed by its benefits ( perception of the benefits
of, costs of and barriers to an action).19 The intervention was
focused on information and discussions regarding perceived
Figure 1 Number of students in the intervention group ((IG) and
the comparison groups (CG1 and CG2) completing the baseline
questionnaire, participating in the intervention, and completing
the follow-up questionnaire
559
susceptibility and perceived severity of the viral infection. The
intervention was theory-based, as it has been suggested that
theory-based interventions have a more positive effect than
those that are not theory-based,15,20 and included skill training
as it has been indicated that this can affect change in sexual
behaviour.21
Intervention
An intervention took place during the spring of 2009 and
involved a one-hour lesson about HPV and preventive
methods, with special focus on vaccination and condom use.
The lesson started with a 15- to 20-minute long presentation
about HPV, its frequency, what it can lead to and how
to prevent it. Information on the effectiveness, price and
side-effects of the vaccines was included as well as the fact
that the vaccines do not protect against all HPV types that
can cause cervical cancer and the importance of cervical screen-
ing. This was followed by information on how to use a condom
and how to put it on. Different types of condoms were intro-
duced and demonstrated. The lesson also included training of
practical skills through a game called ‘condom relay race’ (i.e.
opening a condom package and practicing rolling it out). The
lesson ended with a discussion on STI and HPV prevention
and then the students received a specially designed folder
about HPV and its prevention, with an enclosed condom. The
students were also invited to see the project’s website about
HPV and other STIs. On the website the students could fill in
a quiz about HPV, and the first 10 who answered the questions
correctly received a movie theater ticket. A new quiz was avail-
able after two weeks and the first 10 who filled it in correctly
also received a movie theater ticket.
High school students studying information technology
designed the website and the folder. The lesson was held by
the first author (registered nurse) together with a specially
trained university student.
We hypothesized that the intervention would improve the
students’ knowledge about HPV and that it would make their
attitudes to preventive methods for cervical cancer more
positive.
Procedure
Principals of six high schools were contacted and gave their
permission for the study.
Before administration of the questionnaires, the students
received verbal and written information about the study.
Participation was voluntary. At baseline, a brief information
text about HPV was available for the students after they had
filled in the questions on knowledge, and before they were to
fill in the questions regarding attitudes. At follow-up, no infor-
mation about HPV was included in the questionnaire. After the
students had completed the questionnaires, they put them in
envelopes and handed them to the researcher or the research
assistant. Assent was obtained by completion of the question-
naires or participation in the lesson.
Instrument
To achieve high validity, the questionnaires were designed on
the basis of findings in previous studies and most questions
560 International Journal of STD & AIDS Volume 21 August 2010
................................................................................................................................................
had been used previously.8,22 The baseline questionnaire con-
sisted of 44 questions. Twelve of these questions concerned
sociodemographic and sexual health characteristics of the stu-
dents, four questions concerned general knowledge of STIs
and sources of information, and 13 questions concerned HPV
knowledge and sources of information. The last 15 questions
sought to determine the students’ attitudes to HPV vaccines,
their attitudes to condom use, alone or in combination with
HPV vaccination or contraceptive pills, and the girls’ attitudes
to Pap smear tests. A few questions were ‘open-ended’ or ‘mul-
tiple choice’, but most questions could be answered with ‘yes’,
‘no’ or ‘don’t know’. Attitudes regarding condom use and Pap
smear in association with vaccination were assessed by means
of a 100 mm Visual Analogue Scale (VAS) ranging from ‘com-
pletely unlikely’ (0) to ‘highly likely’ (100).
Twenty-three questions from the baseline questionnaire were
included in the questionnaire at follow-up. All questions con-
cerning HPV knowledge, four questions concerning attitudes
to cervical cancer prevention and the most relevant questions
concerning sociodemographic characteristics, sexual health
characteristics, and general knowledge of STIs and sources of
information, were included. Only the most relevant questions
of the baseline questionnaire were included to make the
follow-up questionnaire shorter. In the follow-up questionnaire
completed by the IG, 11 questions regarding the students’
opinions about the intervention were added. The primary
outcome variable was knowledge of HPV. Secondary
outcome variables were attitudes to cervical cancer prevention
such as condom use, HPV vaccination and girls’ attitude to
attending Pap smear screening in the future. The instrument
was tested in a pilot study on 12 high school students.
Adjustments to the questionnaire were made on the basis of
the opinions expressed by these students.
Data analysis
Data were entered and analysed using the Statistical Package of
the Social Sciences (SPSS for Windows v. 16.0). The answers
to the 10 questions concerning specific HPV knowledge were
divided into two categories, correct answer ¼ 1 and incorrect
answer/don’t know ¼ 0. To form an index of knowledge, the
10 answers were summed and could add up to a maximum
of 10 points if all answers were correct. Differences between
the groups were tested for significance at baseline and at
follow-up.
Mixed-effects models with a random intercept term for each
cluster (classes) and group as a fixed effect were estimated for
each ‘question’. Intention to attend for Pap smear if vaccinated
was analysed by a linear mixed-effect model. Binary outcome
variables were analysed by a logistic mixed-effect model. The
knowledge index and influence of HPV vaccination on
condom use were markedly non-normally distributed and
were therefore dichotomized and analysed as binary variables.
The knowledge index was categorized as ‘five or more correct
answers’ or ‘less than five correct answers’ and VAS as
‘highly likely’ (90 –100 mm) or ‘not highly likely’ (0–89 mm).
Correlation between ordinal scaled variables was tested
with Spearman’s rank-order correlation. Differences were
considered significant if P , 0.05. Calculations of the reported
percentages were based on the number of students answering
each question, and the internal dropout varied between 0%
and 5%.
The study was approved by the Regional Ethics Committee
in Uppsala, Sweden.
RESULTS
Characteristics
The mean age of the students was 16 years. A majority (76%)
were of Swedish origin. Almost half of the students (46%, n ¼
98) had had sexual intercourse and 67% (n ¼ 66) of them had
used a condom at their first intercourse. Twenty-one percent
(n ¼ 21) had not used any contraceptive method at their first
sexual intercourse. At baseline, the IG had an equal gender dis-
tribution (56 girls/58 boys), but the comparison group (CG1)
included more girls (n ¼ 78) than boys (n ¼ 43) (P ¼ 0.018).
At follow-up, the gender distribution was similar to at baseline.
The second comparison group (CG2) had an equal gender
distribution.
At baseline, more students in the IG (n ¼ 17) than in the
CG1 (n ¼ 6) had tested for an STI (P , 0.001). There was no
difference in this respect at follow-up (P ¼ 0.055).
Knowledge of HPV
In an open-ended question about which STIs the students were
aware of, only one student at baseline mentioned HPV. At
follow-up, 70% (n ¼ 61) in the IG and 7% (n ¼ 7) in CG1
included HPV in the answer (P , 0.001). At baseline, only
one student believed HPV to be the most common STI in
Sweden, but at follow-up, 30% (n ¼ 25) of the IG and 1%
(n ¼ 1) of the CG1 believed so.
As shown in Table 1, the knowledge of HPV in the IG
increased significantly after the intervention. Among the stu-
dents who had heard about HPV at follow-up, students in
the IG reported that they had received their information
about HPV mainly from school (76%, n ¼ 70), whereas a
majority of the students in CG1 reported the media to be the
main source of this information (63%, n ¼ 24).
The median score for HPV knowledge was 1 out of 10 in both
groups at baseline (P ¼ 0.620). At follow-up, the median knowl-
edge score was higher in IG than in CG1 (P , 0.001). In IG the
median knowledge score had increased to 6, and over 80% of
the students had five or more correct answers. In CG1 the
median was still 1 and 13% had five or more correct answers.
Attitudes to HPV vaccination, condom use
and Pap smear
At baseline, 19 students (15%) in IG and nine students (7%) in
CG1 intended to be vaccinated (P ¼ 0.163). Three of these
students were boys (2 in IG, 1 in CG1). Three girls in IG (3%)
and five girls in CG1 (4%) had been vaccinated against HPV
at baseline (P ¼ 0.703). At follow-up, 15 girls in IG (16%) and
15 girls in CG1 (14%) had received the vaccination (P ¼
0.667). At that time, seven students (8%, 4 girls and 3 boys) in
IG intended to become vaccinated and 11 students (11%, 8
girls and 3 boys) in CG1 had this intention (P ¼ 0.344).
Attitudes to condom use were equally positive before and
after the intervention in both groups. Likewise, attitudes to
Pap smear testing did not change in any of the groups after
the intervention.
 Gottvall et al. Educational intervention concerning HPV 561
................................................................................................................................................

Table 1 Awareness of human papillomavirus (HPV)/HPV vaccine and correct answers to specific knowledge questions about HPV
†
among the intervention (IG) and comparison groups (CG1, CG2)
IG CG1
baseline baseline
(n 5 114)/ (n 5 121)/ CG2 Difference IG Difference IG Difference CG2
follow up follow up follow up versus CG1 versus CG1 versus CG1 at
(n 5 92) (n 5 110) (n 5 74) at baseline at follow up follow up
(%) (%) (%) P value P value P value
Heard of HPV 11/100 12/35 24 0.670 ,0.001 0.017
Aware of vaccine against HPV 4/64 4/26 6 0.960 0.032 0.012
Is HPV a virus that spreads through sex? (yes) 9/92 8/36 23 0.979 0.002 0.198
Can HPV affect women? (yes) 11/92 11/39 19 0.782 0.003 0.215
Can HPV affect men? (yes) 4/83 4/11 11 0.768 ,0.001 0.350
Can HPV cause chlamydia? (no) 3/13 2/6 3 0.998 0.153 0.181
Can HPV cause condyloma? (yes) 6/66 3/6 4 0.491 ,0.001 0.653
Do you always notice an HPV infection? (no) 9/74 7/20 18 0.768 0.002 0.173
Does HPV cause cervical cancer in women? (yes) 10/71 9/33 22 0.940 0.024 0.192
Does HPV cause other types of cancer? (yes) 0/35 4/4 7 0.640 0.005 0.659
Can HPV cause herpes infection? (no) 0/15 1/1 1 0.794 0.026 0.734
How effective is the vaccine? (70%) 48/44 49/50 44 0.548 0.490 0.453
Median number of correct responses on 10 1/6 1/1 1 0.620 ,0.001 0.912
questions concerning HPV knowledge

P value from a mixed-effects logistic model with a random intercept term for each cluster (class)
†
CG1 completed the baseline and the follow-up questionnaires. CG2 only completed the follow-up questionnaire
P , 0.05

Attitudes to the intervention
More than half of the boys (55%, n ¼ 23) and one-fourth of the
girls (25%, n ¼ 12) considered that the intervention had
increased their knowledge a lot. A few students, 12% (n ¼ 5)
of the boys and 8% (n ¼ 4) of the girls considered that it had
not increased their knowledge at all or very little. There was
a fair correlation between believing that the intervention had
increased the knowledge and a higher knowledge score (rs ¼
0.410, P , 0.001). The lesson was seen as the most valuable
part of the intervention (55%, n ¼ 51). Almost half of the
students (46%, n ¼ 41) had read the folder and 33% (n ¼ 30)
had visited the website.
Differences between the two comparison
groups at follow-up
Students in CG1 were aware of HPV and HPV vaccines to a
higher extent than students in CG2, but no differences were
found regarding the specific knowledge questions (see
Table 1). Thirteen girls (36%) in CG1 and four girls (11%) in
CG2 had been vaccinated against HPV (P , 0.001). No differ-
ences were found between the two comparison groups con-
cerning attitudes to condom use and attitudes to Pap smear
screening in the event of HPV vaccination.
DISCUSSION
In this study we evaluated the effect of an educational interven-
tion regarding HPV that was developed specifically for adoles-
cents in a school setting. Apart from increased knowledge this
intervention did not convincingly show any influence on atti-
tudes to condom use, HPV vaccination and, among girls, the
attitudes to Pap smear screening. About 15% of the girls, both
in IG and in CG1, were vaccinated between baseline and
follow-up, possibly explaining that fewer students at follow-up
than at baseline intended to get vaccinated. Filling in the
questionnaire might have been enough for some girls to take
the steps to vaccination (i.e. the Hawthorne effect), but there
was also an intensive direct-to-consumer campaign during
this period from one of the vaccine manufacturers. In concor-
dance with previous findings,7,8 the baseline knowledge was
low in this study. At follow-up, the knowledge of HPV was
higher in IG than in CG1. The knowledge of HPV was slightly
higher in CG1 than in CG2. An explanation for this might have
been that the CG1 had gained knowledge through participation
in the study.
The attitudes to condom use were equally positive and unaf-
fected by the intervention, regardless of study group. The atti-
tudes to HPV vaccination and Pap smear screening were also
unaffected by the intervention. It might be difficult for high
school girls to have an attitude about Pap smear screening,
since in Sweden women are recommended to attend screening
every third year starting from the age of 23 to 25 years.
Despite the availability of an easily read folder and a website
designed by peers, the lesson about HPV was the most appreci-
ated part of the intervention. Few of the students reported that
they had visited the website, although most adolescents in
Sweden have access to the Internet and are frequent computer
users.23 An hour long lesson can apparently make a bigger
impression on adolescents than distributed written material.
However, written material has also been found to be effective.
An educational protocol about HPV and Pap smear tests for
adolescents has been reported to increase knowledge of HPV
among study participants visiting an adolescent clinic.24 This
suggests that simple interventions with limited resources can
improve knowledge of HPV. However, knowledge represents
only one step in prevention of HPV and cervical cancer.
Changing to a preventive behaviour is complex even when
good knowledge is obtained; the potential benefits of the pre-
ventive behaviour have to be considered to outweigh the cost
or other possible barriers.19
Providing correct, gender-sensitive and balanced information
about sexual health issues is a challenging task. Sweden has
been a leading country in school-based sexual and reproductive
562 International Journal of STD & AIDS Volume 21 August 2010
................................................................................................................................................
health (SRH) education for many years. Such education was
previously offered at all levels in school, but nowadays it is
only included in levels lower than high school. As a conse-
quence this has led to insufficient knowledge about SRH
among adolescents, and they are now requesting more infor-
mation about reproduction and STIs.25,26
Our study had limitations. There were fewer boys in CG1
than in CG2. If, in general, girls have better knowledge in this
area, the total knowledge in CG1 would decrease if more boys
were added. However, this would not affect the main results.
The response rate was low at follow-up. A total of 330
students were required to obtain a power of 80% but was not
reached due to varying attendance of the students in the
classroom on the day of data collection. Conclusions based
on statistically significant differences between groups are unaf-
fected while non-significant differences have to be cautiously
interpreted due to lack of power.
Performing a large number of statistical tests increases the
risk of mass significances. This risk was limited by a conserva-
tive interpretation of the analyses.
CONCLUSION
The baseline knowledge of HPV was very low among the
16-year-old students. Our study has shown that a short school-
based intervention greatly can increase the students’ knowledge
about HPV, but that attitudes and behaviours are less easy to
influence.
ACKNOWLEDGEMENTS
The study was funded by the Swedish Cancer Society
(Cancerfonden) and The Jerring Foundation.
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